<div class="upperLayer" id="regForm">
    <div id="btnClose"><a href="javascript: void()" onclick="closeLayer()">Close</a></div>
    <br />
    <p>Add a Customer</p>
    <form method="post" action="" onsubmit="return addUser('<?php echo  $this->baseUrl();?>/admin/customers/add')">
	    <table id="regTb">
	    	<tr>
	    		<td class="leftCol"><label for="txtUsername">Username: </label></td>
	    		<td class="rightCol"><input id="txtUsername" name="txtUsername" type="text" /></td>
	    	</tr>
	    	<tr>
	    		<td class="leftCol"><label for="txtPassword">Password: </label></td>
	    		<td class="rightCol"><input id="txtPassword" name="txtPassword" type="password" /></td>
	    	</tr>
	    	<tr>
	    		<td class="leftCol"><label for="txtFirstname">*Firstname: </label></td>
	    		<td class="rightCol"><input id="txtFirstname" name="txtFirstname" type="text" /></td>
	    	</tr>
	    	<tr>
	    		<td class="leftCol"><label for="txtLastname">*Lastname: </label></td>
	    		<td class="rightCol"><input id="txtLastname" name="txtLastname" type="text" /></td>
	    	</tr>
	    	<tr>
	    		<td class="leftCol"><label for="txtEmail">*E-mail: </label></td>
	    		<td class="rightCol"><input id="txtEmail" name="txtEmail" type="text" /></td>
	    	</tr>
	    	<tr>
	    		<td class="leftCol"><label for="txtPhone">*Phone: </label></td>
	    		<td class="rightCol"><input id="txtPhone" name="txtPhone" type="text" /></td>
	    	</tr>
	    	<tr>
	    		<td class="leftCol"><label for="txtFax">Fax: </label></td>
	    		<td class="rightCol"><input id="txtFax" name="txtFax" type="text" /></td>
	    	</tr>
	    	<tr>
	    		<td class="leftCol"><label for="txtAdd">*Address: </label></td>
	    		<td class="rightCol"><input id="txtAdd" name="txtAdd" type="text" /></td>
	    	</tr>
	    	<tr>
	    		<td class="leftCol"><label for="txtAdd2">Address 2: </label></td>
	    		<td class="rightCol"><input id="txtAdd2" name="txtAdd2" type="text" /></td>
	    	</tr>
	    	<tr>
	    		<td class="leftCol"><label for="txtCity">City: </label></td>
	    		<td class="rightCol"><input id="txtCity" name="txtCity" type="text" /></td>
	    	</tr>
	    	<tr>
	    		<td class="leftCol"><label for="txtBirthday">Birthday: </label></td>
	    		<td class="rightCol"><input id="txtBirthday" name="txtBirthday" type="text" /></td>
	    	</tr>
	    	<tr>
	    		<td class="leftCol"><label for="chkUser">Is user? </label></td>
	    		<td class="rightCol"><input id="chkUser" name="isUser" type="checkbox" /></td>
	    	</tr>
	    	<tr>
	    		<td class="leftCol"></td>
	    		<td class="rightCol"><input id="btnSubmit" name="submit" type="submit" value ="Submit" /></td>
	    	</tr>
	    </table>
    </form>
</div>